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Here's another (long) thread about normalcy bias - this time in relation to healthcare systems breaking down.
I will start by saying the worst case scenario in this thread hasn't happened here yet, but there is a distinct possibility it might happen in some places for a time.
I will start by saying the worst case scenario in this thread hasn't happened here yet, but there is a distinct possibility it might happen in some places for a time.
We have heard a lot of talk about "the NHS under unprecedent pressure", or "hospitals under huge strain". The NHS is a flexible system, and it can deform under pressure without breaking (rupture). But eventually even flexible things will break after reaching their elastic limit.
So what happens if the NHS bends beyond its limit? What does that rupture look like?
@chrischirp has written about this here: https://www.theguardian.com/commentisfree/2021/jan/12/overwhelmed-nhs-covid-britain-hospitals
I wanted to highlight a few things.
@chrischirp has written about this here: https://www.theguardian.com/commentisfree/2021/jan/12/overwhelmed-nhs-covid-britain-hospitals
I wanted to highlight a few things.
Firstly, I think the NHS has, in some senses and in some places, already broken down. Fortunately not widespread yet, but still: we know that our normal expected minimum standards aren't being met for some patients, in multiple ways, in some places, due primarily to covid.
eg We know ICUs are expanding into new areas (often the same areas they used in the first wave) but in many surge ICUs the normal ICU-nurse-to-patient ratio of 1:1 for a ventilated patient is more like 1:3 or even 1:5, supplemented by non-ICU nurses. That's not normal in the UK.
It puts a huge strain on the ICU nurse: managing 3, 4, 5 times the usual number of tasks, working out which ones their assistants can do and which they have to do themselves and when. All this while trying to maintain safety and avoid errors, and wearing smothering PPE for hours.
Another eg is Emergency Depts being so overwhelmed that pts are being treated in the ambulances outside as there's no room to move them inside safely. That's not normal. Not having room inside for all the pts is failing at a very basic level (through no fault of the hospital).
Let's look more widely. The high level of demand caused by covid is sucking resources from every other less urgent condition. We can't help that - if someone presents acutely breathless, you can't send them away - but there is a resource cost, paid by the less urgent patients.
"Elective" (pre-planned) surgery is being cancelled on a huge scale again, as staff get drawn into looking after covid patients. That's millions of outpatient appointments, operations, tests and scans being postponed. That will lead to some patients having worse outcomes.
Part of the problem will be that we'll likely never know which specific patients it was who would have survived longer if their cancer had been treated on time (for example); statistically you know how many excess deaths there've been, but we won't know *who* those deaths were.
But the point is that making so many people wait months for urgent appointments, sometimes in pain, and sometimes with progressing conditions that may pass the point of rescue while waiting, is failing at a basic level as well. NHS care is supposed to be timely and comprehensive.
So you see my point that we may already be seeing an NHS that has - in some locations and in some specialties/types of care - already broken down.
But could it get worse? As @chrischirp touched on, yes, it could.
But could it get worse? As @chrischirp touched on, yes, it could.
Currently we can still, just about, offer something like an level 3 (ventilator) ICU bed to everyone who'd benefit from it. It might be a 1:4 nursing ratio ICU bed, but you get a ventilator and you get appropriate care. Note this is not offered to all pts in normal times anyway.
Admission to ICU is always a judgement call by the team, led by a doctor, about whether the pt would likely benefit. If there's no realistic prospect of their condition improving then there's no purpose to putting someone through the gruelling, unpleasant experience of ICU.
However if they have a potentially reversible condition, need organ support and have reasonable physiological reserve then currently a patient would be offered ICU care (he said, massively oversimplifying the decision-making process). That care may have limits (eg no CPR).
The scenario we desperately hope not to see - and which I stress is NOT currently happening in the UK - is one where the need for ICU beds exceeds even our expanded surge ICU capacity, we cannot create any more ICU beds, and we find ourselves in a triage situation.
In that situation, doctors would then be faced with choosing which of several potentially-benefiting patients is the one who gets admitted to the only available bed. All of them would normally be admitted; in this situation, only one can be. Who should it be? This is triage.
You may or may not be able to transfer the other potential ICU patients out to another hospital which does have some capacity; in this scenario you may not have the staff to do the transfer, and transfers are not good for patients anyway due to the effect of the journey on them.
Now that is the scenario where the most resource-heavy care, ICU, is the care being rationed. It could get worse. You could be looking at, say, oxygen running out in a hospital (many hospitals have had to expand their oxygen stores/VIEs to meet demand), or just simply no room.
We have not reached that stage yet, but the ICU beds could run out before the peak is reached and the curve bends. The @Nuffbioethics put out a statement this week calling for national guidance on how to manage that situation, should it occur. This is urgently needed.
Here is the @Nuffbioethics statement. The guidance was supposed to come out last year but never did (and despite rumours, hospitals never *quite* ran out of ICU beds overall, though it got hairy at times and there were a LOT of transfers around regions). https://www.nuffieldbioethics.org/news/statement-the-need-for-national-guidance-on-resource-allocation-decisions-in-the-covid-19-pandemic
(I should add that it's not that pts in a triage situation, unable to get into an ICU bed, would just be left to die without any care. They would still get the best available treatment on a general ward, or if beyond that stage, palliation to keep them comfortable and pain-free.)
The BMA put out some guidance along these lines last year (now updated) but we have never, so far, quite reached the stage where it has been needed in this way in the UK. https://www.bma.org.uk/advice-and-support/covid-19/ethics/covid-19-ethical-issues-when-demand-for-life-saving-treatment-is-at-capacity
We all hope desperately we don't get to that point and that we do not end up having to choose who gets ICU care. But even if the curve bends and case numbers start to fall, even as the wave of covid recedes, the retreating pandemic tide will reveal a devastated NHS.
Our staff are being traumatised by this pandemic, and its relentlessness and cruelty. The seemingly endless waves of sick, breathless and scared patients, each a threat to the staff member's own life, are taking their toll on those who are putting themselves at risk to give care.
We also know that even once the covid wards have started to empty, after the ICU surge units close as ICU contracts back to its usual footprint, we still have an intimidatingly huge backlog of other people who have been anxiously but patiently waiting for care.
So this will continue to affect the NHS for years to come, even if we magically somehow were to eliminate covid this year and return to "normal" in relation to infection control and demand for respiratory support (ICU or ward-based).
Huge waiting lists, ongoing covid problems, staff reductions as people leave once they feel their pandemic duty is done, and (yes, incredibly) yet further planned reorganisations will combine to make the NHS's job much harder than otherwise, and for a long, long time.
But how does this relate to normalcy bias? I've written about this psychological phenomenon before, and it is relevant in a surprisingly wide range of situations - the UK experience of this pandemic being one of them. https://medium.com/@thomasdolphin/surrounded-by-fire-hoping-for-the-best-e7f07fa9d9c6
Normalcy bias shows itself in the belief that, because everything has always worked out okay in the end previously in similar bad situations, if we just wait or carry on doing what we've always done then it'll be okay this time, too.
It's the reason we have things like difficult airway algorithms to carry you past the normalcy bias that keeps you repeating easy steps that aren't working, and force you to make the difficult decision to acknowledge that the abnormal situation requires an extraordinary response.
So here we are with an extraordinary situation occurring in the NHS, a possible rupture ahead, and we seem to be in the grip of national normalcy bias on this (as on so many other things). Is this situation extraordinary enough that we need to do something extraordinary now?
I agree with the Nuffield Bioethics people that guidelines on triage ethics need to be produced ASAP, and agree with @theBMA, @MPS_Medical and others that doctors and nurses need legal protection as well, because the fallout from this will be huge. https://www.bbc.co.uk/news/uk-55689388
We need to recognise that we are on the brink of an extraordinary and deeply alarming moment for the NHS that will be a watershed in how we think about it if things go as badly as they might. Let's cross everything that it doesn't come to that and that we locked down in time. 
And even if we do just pull back from the edge of that dark hole, we mustn't pretend that we "just about got away with", for all the other reasons mentioned above that show the NHS has not coped in any meaningful way. We have to learn from this or it will happen again, for sure.
